Healthcare Advocates Explain How to Navigate ACA in New York State

Kyle Brittingham, Small Business Assistance Program, explains how Affordable Care Act tax credits work for small businesses. Flor Ramirez, of NY State of Health is seated to his right.

With the March 31st deadline quickly approaching for health insurance enrollment under the Affordable Care Act (ACA), White Plains-based Westchester Children’s Association decided to reach out to local media with a morning informational seminar last Thursday to advocate for the program and explain where financial assistance is available and how it can be obtained.

Lorraine Gonzalez, Director of Health Policy for the Children’s Defense Fund, opened the meeting. “There is a lot of misinformation out there, especially in the press,” Gonzalez said. “We need to keep working so people know what their options are and to get as many families and children signed onto healthcare as possible.”

Flor Ramirez with NY State of Health, explained that when the ACA opened for state options, New York was motivated, proactive and ahead of many other states in providing assistance. There is an extensive network in place with over 146 qualified organizations, able to speak in numerous languages, providing advocacy and navigation to help applicants through the system.

To show how far ahead of the curve New York State is, Ramirez explained that some states have nothing in place, while New Jersey has only five qualified organizations acting as health care navigators.

NY State of Health is the official health plan marketplace for New York residents and is the only place where small businesses and individuals can apply for and receive financial assistance to help pay for coverage. If a state resident goes to the national ACA site, they are immediately directed to NY State of Health where they can enroll in a qualified health care program in either the individual or small business marketplace.

The Marketplace includes 16 qualified health plans with such well-known agencies as Empire, Blue Cross Blue Shield, Excellus, and Health First. Some of the plans cover dental.

In order to qualify for the marketplace and for applicants to receive financial help, a health care plan must cover 10 essential health benefits according to the ACA. These include preventative, wellness and chronic disease management; inpatient care; outpatient services; mental health and substance abuse disorder services; emergency services; lab and imaging; prescription drug; rehabilitative and habilitative; maternity and newborn care; and pediatric dental and vision coverage.

The plans are available at four service tiers: platinum, gold, silver and bronze. Each must have an adequate network and all state consumer and provider protections must be in place.

New patient protections under ACA include plans that cover preventive care with no cost sharing; no lifetime benefit caps; no unreasonably low annual benefit caps; the right to appeal when a patient disagrees with the health plan; young adults (under 26 years) can get coverage through their parent’s insurance; and no pre-existing condition exclusions after 2014.

“About 75 percent of individuals who enroll through the Marketplace will qualify for tax credits to help them pay for coverage,” Ramirez said. “A family of one with an annual income under $45,950 will get help,” she added. For a family of four, financial help is available at an annual income of $94,200 or less.

Cost-sharing credits lower co-payments and deductibles are available to single adults earning less than $28,725 annually and for families of four earning less than $58,875.

Ramirez explained that the methodology used to determine affordability is based on healthcare costs taking 9.5 percent of annual personal income.

For small businesses, Kyle Brittingham of the Small Business Assistance Program, explained that a small business or a non-profit that has fewer than 25 full-time employees (two half-time employees count as one full-time employee) with average annual wages less than $50,000, not counting the wages of the owner or members of the owner’s family, will qualify for tax credits. “As much as 50 percent of premiums might be paid through tax credits,” Brittingham said.

Brittingham also emphasized that there is no mandate for small employers with fewer than 50 full-time equivalent employees to offer healthcare benefits, but for larger companies penalties will apply.

There is a tool on the nystateofhealth.ny.gov website organized by county that will allow an applicant to view average prices for their area and how much aid they might receive based on their income or business size. There also is a complete list of qualified navigators on the site who will set up an appointment to work with an applicant in person.